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Dr. Gary, Dog Veterinarian

Category: Dog Veterinary

Satisfied Customers: 18257

Experience: DVM, Emergency Veterinarian, BS (Physiology)

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My 13 yr. old dachshund has elevated liver enzymes (ALP 918

Customer Question

My 13 yr. old dachshund has elevated liver enzymes (ALP 918 & ALT 227). This started when he had his teeth cleaned and some pulled 3 months ago. 2 wks ago he coughed and breathed rapidly with very bloodshot eyes. Vet x-rayed and found a moderate bronchial pattern to suggest bronchitis. Clavamox and steroid eye drops given, but 2 wks. later, still an issue. He is extremely itchy all over, waters from his eyes, and has skin peeling off the bottoms of his foot pads. I have read up on this for many days and wonder if he doesn't have a systemic (or lung) fungal type infection. The vet, to appease me, gave me Ketoconazole for him. Is that safe for his liver? I have spent $3K on him this yr. alone, and want answers! Bloodwork, ultrasound, x-rays, exams. You would think something would get figured out! Vet says no pneumonia 2 wks ago & lungs sound better now, but not perfect. Could he have Blastomycosis? He has all the signs of it. I am happy to fax all his results if needed. Help! Trish

I live in Boise, Idaho. Jake has never had a bile acid test or a liver biopsy. He is breathing somewhat better since the antibiotic 2 wks. ago, but still not completely normal. The liver biopsy was discussed in the beginning. Besides being so expensive, I didn't want to knock him out again and cause more trauma to his system. I asked what we do either way and the vet said Denosyl, so just began to treat his liver. My main concern is how hard on his liver the Ketoconazole will be. His bloodshot eyes are a concern and I feel a sign of "something". He's never had this happen before in 13 yrs. When I see the vet it seems we are coming up with zero answers and he just keeps acting like it's probably just some allergic bronchitis and that he is fine. And although I would love to believe that myself, the continued coughing after 2 wks. and still bloodshot eyes are a concern to me. The vet said that his heart looked fine, he has an enlarged liver, but no pneumonia was present with the x-ray. He's always had anal gland issues and has them expressed every 2 months or so. He just had this done 3 wks. ago., yet is still licking his bottom. He chews all his feet, licks his arms and but and rubs his face and chin all over everything. It's like he is itchy all over. He's always had a little of this, but now it's extreme. Last Sept. he had itchy skin and when they tested it, it was yeast. He got Ketoconazole back then for 2 wks. to clear that up. His bloodwork actually looked great before the teeth cleaning. It seems that ever since that happened he has been just struggling along now. I wish I had never got this done.

My thought is that the vet could have at least ruled out other things by doing a fecal test, urinalysis, cytology, etc. I don't want to tell him (or suggest) how he should do his job, but for the prices, seems he should be reaching a bit further. All the hours of reading I've done have educated me, but also have made me worry more. From what I read, Ketoconazole is not only hard on the liver of pets, but it also stops the adrenal glands from over producing steroid (cushings dogs). My vet didn't even know this. Strange? Maybe I should just look for a new vet.

Here is how I would proceed- my thought is that we need to tie this all together into one diagnosis. My main differentials are: 1. Fungal disease (Blasto) 2. Hepato-cutaneous syndrome where the liver failure leads to cutaneous/ skin signs 3. Auto-immune disease- Lupus is a concern

Tests that are worth running and minimally invasive: 1. Urine blasto test- we can easily rule out blasto by sending out a urine fungal screening 2. Bile Acids Test- this is the only way to check liver function. It's a blood test and we run it over 2 hours. If normal, then the liver function is normal and we ruled out liver disease, hepato-cutaneous, liver cancer. 3. Coomb's/ ANA- this tests for auto-immune disease like Lupus. Again it's a blood test and gives us information right away with minimally invasive techniques. 4. Tonometry on the eye- this tests the eye pressure like the puff of air at the ophthalmologist. If low, then this is inflammation behind the cornea (uveitis) that is common with Blasto. If high, then it's glaucoma (not likely). If normal, then the red eye is likely conjunctivitis and topical steroid drops should help.

More invasive testing if needed: 1. Liver Biopsy- if the bile acids is abnormal, then we need a liver biopsy to get the diagnosis on what's wrong with the liver- cancer, auto-immune, hepato-cutaneous, chronic active hepatitis, hepatitis, ect. 2. Trans-Tracheal Wash- if everything is normal, then I'd get a wash of what's in the lungs (under light anesthesia) to find out what is causing the signs in the lungs- pneumonia, fungal disease, cancer

As for the Ketoconazole and the liver- it's not really that bad on the liver. If we have elevated bile acids, then I'd alter my dose but even a diseased liver can handle Ketoconazole. I really want a diagnosis of fungal disease before starting it though, as Ketoconazole for fungal disease is a 4-6 month treatment protocol, not the 7-14 days like with skin yeast infections. We can also use it to suppress the adrenals, but we use a higher dose and honestly nobody is really doing this anymore. When you stop the Ketoconazole, the adrenals rebound nicely and it actually doesn't work all that well to suppress the adrenals. It's more of a possible adverse effect, not an expected effect.

To be honest, this case would be best handled by an internal medicine specialist. I know they're more expensive, but at least you'll get the diagnosis after one visit as opposed to throwing multiple drugs at him and ending up at square one over and over again.

I hope this helps give you some information to work with, let me know if you have any other questions.

Wow! That's the most extensive and best info. I've gotten so far. Thank you!! Last question:

How do I find a vet that specializes in Internal Medicine? Should I maybe seek a professional in an Emergency / Specialty center? We have one here called WestVet. I would like to bring all my current paper results and your email.

Thank you for all your help. Now I will be able to get to the bottom of it.

WestVet looks like a good referral/ ER facility (just checking out their site) where they can offer the diagnostics needed as well as 24 hour care. That's the route I'd go to get the diagnostics done and get to the bottom of this.

How do I get a referral from you for Dr. Ochoa at WestVet in Boise, Idaho? She is the only internal medicine specialist in Boise, and works by referral only. I don't want to have to go to Jake's original vet again for this. Can you help out so that I don't have to do that?

I will tell you that...the things you have to go through to be an Expert are quite rigorous.

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